The definitions contained in G.S. 58-50-56(a) are
incorporated into this Section by reference and as used in this Section, the
following terms have the meanings ascribed to them:

(1) "Coinsurance" means the percentage of an
allowed charge or expense, or usual and customary charge for a covered health
care service that an enrollee must pay.

(2) "Copayment" means a fixed dollar amount
that an enrollee must pay each time a covered health care service is provided.

(3) "Deductible" means a specified amount of
covered health care services, expressed in dollars, that must be incurred by an
enrollee before the insurer will assume any financial liability for all or part
of covered health care services.

(5) "Enrollee" means an individual who is
covered by a PPO benefit plan.

(6) "In-network covered services" means
covered health care services that are received according to the rules of the
health benefit plan from providers employed by, under contract with, or
approved in advance by the insurer; and means emergency health care services
regardless of the status or affiliation of the provider of such services.

(7) "Out-of-network covered services" means
non-emergency, medically necessary covered health care services that are not
received according to the rules of the health benefit plan, including services
from affiliated providers that are received without the approval of the
insurer.

(8) "Out-of-pocket expense" means a specified
dollar amount of coinsurance incurred and payable by an enrollee for covered
health care services in a specified period. Out-of-pocket expense may or may
not include deductible amounts, copayment amounts, charges in excess of the
amount allowed by the insurer, amounts exceeding the maximum benefits, or any
other disallowed or noncovered expenses under the rules of the health benefit
plan.

(9) "PPO benefit plan" has the same meaning
as "preferred provider benefit plan" in G.S. 58-50-56(a)(3).

History Note: Authority G.S. 58-2-40; 58-50-56;

Temporary Adoption Eff. January 1, 1998;

Eff. August 1, 1998;

Pursuant to G.S. 150B-21.3A, rule is necessary without
substantive public interest Eff. May 1, 2018.